Sir,
A 57-year-old Caucasian man was diagnosed with autoimmune hemolytic anemia (AIHA) in December 2017. He had been treated, for his AIHA, with a gradually reduced course of oral methylprednisolone starting from 32 mg once daily tapered to 4 mg once daily within 12 months, valaciclovir 500 mg once daily, filicine 5 mg once daily, trimethoprim/sulfamethoxazole (800 + 160 mg) once daily, oral fluconazole 200 mg once daily, and oral dimethindene 10 mg once daily. His past medical history included essential hypertension and type 2 diabetes mellitus. He was on treatment with oral metformin 500 mg three times a day, insulin glargine 20–30 units daily and eprosartan, an angiotensin II receptor antagonist, 600 mg once daily. In October 2018, after failing the aforementioned medications, he was started on rituximab originator (MabThera) 750 mg intravenously once weekly for 4 consecutive weeks. Seven weeks after the first infusion of rituximab, he developed widespread erythrodermic psoriasis affecting his trunk, limbs, neck, and face. At that time, the patient was referred to our dermatology department for review. On examination, he had widespread erythematous psoriatic plaques on the trunk, upper and lower limbs, face, and neck [Figure 1] clinically more in keeping with erythrodermic psoriasis. He reported that in the last one year, he had developed multiple scaly erythematous papules and plaques on his trunk, upper and lower limbs that severely deteriorated in the last 7 days. Upon review of his notes, there was a history of mild erythematous plaques on elbows in the last 6 years that flared up every summer but he had not previously visited a dermatologist for this. He also reported that his father had similar scaly erythematous plaques on his elbows. Acute infections in the last 6 months were not reported. A skin biopsy specimen was consistent with psoriasis [Figures 2 and 3]. He was initially started on treatment with topical emollients, soap substitutes, and oral prednisolone 20 mg once daily with gradual tapering over an eight-week period for his erythrodermic psoriasis. Two weeks after having started oral prednisolone, he was administered also oral methotrexate 10 mg once weekly that was increased after 2 weeks to oral methotrexate 12.5 mg once weekly achieving almost complete remission of psoriasis within 4 weeks. No further rituximab cycles were given. The patient is receiving ongoing follow-up with the hematology department.
Figure 1.
Widespread psoriatic plaques on the trunk and limbs
Figure 2.
Histology showed psoriasiform epidermal hyperplasia with intraepidermal collection of neutrophils and mild lymphocytic infiltrate in papillary dermis (hematoxylin-eosin stain; magnification: ×4)
Figure 3.
The epidermis shows thickening (acanthosis) with regular rete ridges and parakeratosis. Papillary dermis shows a chronic inflammatory infiltrate (hematoxylin-eosin stain; magnification: ×20)
The close temporal association between the rituximab infusions and the onset of erythrodermic psoriasis together with the almost complete recovery after 8 weeks pointed out a drug-related adverse event.
Between 2007 and 2016, 16 cases of new-onset psoriasis and 6 cases of exacerbation of psoriasis were reported in patients taking rituximab.
Fifteen case reports have described the development or exacerbation of chronic plaque psoriasis secondary to rituximab[1,2,3,4] and one multicenter analysis reviewed 1927 patients taking rituximab for rheumatoid arthritis [Table 1].[5] Two patients developed psoriasis and five patients had an exacerbation of preexisting psoriasis.[5]
Table 1.
Summary of rituximab (RTX) induced or exacerbation of psoriasis cases
| Author | Year | Country | Age | Sex | Disease | Rheumatoid factor/anticyclic citrullinated peptide | Past medical history of psoriasis | Lesion sites |
|---|---|---|---|---|---|---|---|---|
| Dass S. | 2007 | Leeds, United Kingdom | 17 | Female | Rheumatoid arthritis (RA) | –/– | No | Scalp, onycholysis |
| Dass S. | 2007 | Leeds, United Kingdom | 52 | Female | Rheumatoid arthritis | +/+ | No | Knees, extensor surfaces of thighs |
| Dass S. | 2007 | Leeds, United Kingdom | 26 | Female | Systemic lupus erythematosus (SLE) | –/– | No | Widespread, elbows, arms, thighs, trunk, onycho lysis |
| Mielke F. | 2008 | Berlin, Germany | 66 | Female | NHL | Not available (N/A) | No | Scalp, extensor surfaces |
| Markatseli T.A. | 2009 | Ioannina, Greece | 55 | Female | Rheumatoid arthritis | +/+ | No | Arms, thighs |
| Brunasso A. | 2011 | Gratz, Austria and Genoa, Italy | 45 | Female | Rheumatoid arthritis | +/+ | No | Plantar psoriasis |
| Guidelli G.M. | 2012 | Siena, Italy | 69 | Female | Rheumatoid arthritis | +/+ | No | Diffuse psoriatic lesions, trunk and arms |
| Hardcastle S. | 2012 | Swindon, United Kingdom | 49 | Female | Rheumatoid arthritis | –/– | Guttate psoriasis in her teens | Acral psoriasis, ankles and heels |
| Thomas L. | 2012 | Creteil, France | 66 | Female | Rheumatoid arthritis | –/– | No | Not available (N/A) |
| Thomas L. | 2012 | Creteil, France | 79 | Female | Rheumatoid arthritis | –/– | No | Elbows |
| Thomas L. | 2012 | Creteil, France | 41 | Female | Rheumatoid arthritis | N/A | Yes, exacerbation of psoriasis | Scalp |
| Thomas L. | 2012 | Creteil, France | 73 | Female | Rheumatoid arthritis | Not available (N/A) | Yes, exacerbation of psoriasis | Palmoplantar pustular psoriasis |
| Thomas L. | 2012 | Creteil, France | 58 | Female | Rheumatoid arthritis | Not available (N/A) | Yes, exacerbation of psoriasis | Legs |
| Thomas L. | 2012 | Creteil, France | 60 | Female | Rheumatoid arthritis | Not available (N/A) | Yes, exacerbation of psoriasis | Palmoplantar pustular psoriasis and elbows |
| Thomas L. | 2012 | Creteil, France | 67 | Female | Rheumatoid arthritis | Not available (N/A) | Yes, exacerbation of psoriasis | Legs |
| Toussirot E. | 2013 | Besancon, France | 44 | Female | Rheumatoid arthritis | –/– | No | Scalp |
| Ming Yee Mok M. | 2013 | Hong Kong and China | 51 | Male | Idiopathic membranous nephropahty (IMN) | Not available (N/A) | No | Pustular psoriasis trunk and limbs |
| Ozen G. | 2013 | Istanbul, Turkey | 50 | Female | Rheumatoid arthritis | +/– | No | Extremities, guttate |
| Jayasekera P. | 2014 | Liverpool, United Kingdom | 80 | Female | Rheumatoid arthritis | Not available (N/A) | No | Right plantar pustulosis |
| Fiorillo L. | 2014 | Alberta and Vancouver, Canada | 16-months old | Male | Idiopathic thrombocytopenic purpura (ITP) | Not available (N/A) | No | Legs, scalp, back, and arms |
| Venables Z.C. | 2015 | Northampton, United Kingdom | 53 | Female | NHL | Not available (N/A) | No | Palmoplantar |
| Kim D.W. | 2016 | Chonbuk, South Korea | 6 | Male | NHL | Not available (N/A) | No | Shoulder, chest, abdomen and back and whole scalp |
| Koumaki D. | 2019 | Heraklion, Greece | 57 | Male | Autoimmune hemolytic anemia (AIHA) | –/– | Yes | Erythrodermic, widespread, trunk, limbs, neck |
| Author | Diagnosis | Psoriasis onset after rituximab | Total rituximab cycles | Rituximab originator/r biosimilar use | Therapy | Rituximab continuation | Prognosis of psoriasis | |
| Dass S. | Clinical, dermatology review | Six months after first cycle | 1 | Rituximab originator | Topical and systemic | Not available | Active | |
| Dass S. | Clinical, dermatology review | 4 months after second course | 2 | Rituximab originator | Topical steroid | Not available | Resolution after 3 months of treatment | |
| Dass S. | Clinical, dermatology review | 4 months after second course | 1 | Rituximab originator | Topical steroid | Not available | Partial remission | |
| Mielke F. | Clinical, rheumatology review | 6–8 weeks after first cycle | 8 | Rituximab originator | Topical steroids, MTX and oral steroid | Yes | Resolution | |
| Markatseli T.A. | Clinical and biopsy | 10 days after second course | 2 | Rituximab originator | Topical steroids | Not available | Not available | |
| Brunasso A. | Clinical and biopsy | 4 months after first dose of rituximab | 1 | Rituximab originator | intramuscular methylprednisolone topical steroids, MTX | No | Complete remission | |
| Guidelli G.M. | Clinical and biopsy | 3 months after second course | 1 | Rituximab originator | Topical steroid | Not available | Complete resolution | |
| Hardcastle S. | Clinical, dermatology review | 10 weeks after first cycle | 1 | Rituximab originator | Topical treatment with steroid, salicyclic acid and coal tar | Not available | Resolution | |
| Thomas L. | Clinical rheumatology review | 6 months after first cycle | 2 | Rituximab originator | Nil | Yes | Resolution | |
| Thomas L. | Patient reported developing psoriasis, no medical input, doubtful diagnosis | 2 weeks after second course | 3 | Rituximab originator | Nil | Yes | Full resolution | |
| Thomas L. | Clinical, dermatology review | 4 months after the second infusion of the third rituximab course | 3 | Rituximab originator | Not available | Not available | Improvement within 3 months | |
| Thomas L. | Not available (N/A) | 4 months after the first course | 2 | Rituximab originator | Topical treatment | Not available | Improvement | |
| Thomas L. | Not available (N/A) | 4 months after the second infusion of the first rituximab course | 3 | Rituximab originator | Topical treatment | Not available | Improvement | |
| Thomas L. | Not available (N/A) | 7 months after the second infusion of the first rituximab course | 1 | Rituximab originator | Nil | Not available | Cleared spontaneously | |
| Thomas L. | Not available (N/A) | 8 months after the second infusion of the second rituximab course | 3 | Rituximab originator | Topical treatment | Yes | Improvement | |
| Toussirot E. | Clinical, dermatology review | Five months after the first RTX administration | 1 | Rituximab originator | N/A | Yes | Stable | |
| Ming Yee Mok M. | Not available (N/A) | Three months after of completion of RTX treatment | 2 | Rituximab originator | Topical treatment | No | Gradual improvement | |
| Ozen G. | Clinical dermatology review and biopsy | 25 months after first infusion | 3 | Rituximab originator | Topical treatment | Yes | Deterioration | |
| Jayasekera P. | Clinical, dermatology review | 2 years after starting rituximab | N/A | Rituximab originator | Topical steroid treatment | No | Cleared completely | |
| Fiorillo L. | Clinical dermatology review and biopsy | 7 weeks after starting RTX | 6 | Rituximab originator | Topical steroid, MTX but discontinued due to intolerance | Yes | Cleared after 1 year | |
| Venables Z.C. | Clinical dermatology review | 2–3 weeks after each cycle RCVP, she developed pustules on her soles and 2 weeks after the initial infusion of RTX she developed severe palmoplantar pustulosis | 6 | Rituximab originator | Potent topical steroids | No | Complete remission, no further relapse | |
| Kim D.W. | Clinical dermatology review and biopsy | 3 months after starting RTX | 3 | Rituximab originator | Topical treatment | Yes | Complete remission | |
| Koumaki D. | Clinical dermatology review and biopsy | 7 weeks after first infusion | 2 | Rituximab Originator | Topical and systemic treatment, oral prednisolone and MTX | No | Partial improvement | |
RTX=Rituximab, RF=Rheumatoid factor, anti-CCP=Anticyclic citrullinated peptide, PMH=Past medical history, F=Female, M=Male, RA=Rheumatoid arthritis, NHL=Non-Hodgkin lymphoma, IMN=Idiopathic thrombocytopenic purpura, DM=Dermatomyositis, SLE=Systemic lupus erythematosus, MTX=Methotrexate, N/A=Not available, RCVP=Intravenous rituximab, cyclophosphamide, and vincristine with oral prednisolone, AIHA=Autoimmune hemolytic anemia
To the best of our knowledge here, we have reported a rare case of erythrodermic psoriasis after rituximab treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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